Most genital trauma occurs in men and may involve injury to the testes, scrotum, and penis. Severe genital injuries occur most commonly on the battlefield because of the ground explosives commonly used. Genital mutilation of women by removing the clitoris, which is done in some cultures, is a form of genital trauma and child abuse.
Most testicular injuries result from blunt trauma (eg, assaults, motor vehicle crashes, sports injuries); penetrating testicular injuries are far less common. Testicular injuries are classified as contusions or, if the tunica albuginea is disrupted, as ruptures.
Scrotal injuries may be caused by burns, avulsions, and penetrating trauma.
Penile injuries have diverse mechanisms. Zipper injuries are more common in children. Penile fractures, which are ruptures of the corpus cavernosum, occur most often when the penis is forcibly bent during sexual activity and can be accompanied by urethral injury. Amputations (usually self-inflicted or due to clothing trapped by heavy machinery) and strangulations (usually due to constricting penile rings used to enhance erections) are additional mechanisms. Penetrating injuries, including animal and human bites and gunshot wounds, are less common; gunshot wounds often involve the urethra.
Symptoms after a direct scrotal blow are usually scrotal pain and swelling. Signs may include scrotal discoloration and a tender, firm scrotal mass that fails to transilluminate, suggesting a hematocele. Scrotal penetration suggests the possibility of testicular involvement. Often the examination is limited by patient discomfort. Penile fractures typically occur during intercourse and result in a cracking sound, immediate pain, marked penile swelling and ecchymosis, and usually a visible deformity. The presence of hematuria suggests the possibility of a concomitant urethral injury.
Diagnosis of external scrotal and penile injuries usually can be made based on physical examination alone. Imaging, such as MRI and sonography, can be considered in equivocal cases of penile trauma. An x-ray with urethral contrast (retrograde urethrography) should be done for penile fracture or penetrating penile trauma when urethral injury is suspected (eg, with hematuria or inability to void). Clinical diagnosis of testicular contusions and ruptures can be difficult because the degree of injury may be out of proportion to the physical findings, so patients with blunt testicular injury typically require scrotal ultrasonography.
Nonoperative management is appropriate for many injuries. Patients with penetrating testicular injuries or clinical or sonographic characteristics that suggest testicular rupture require surgical exploration and repair. Similarly, all penile fractures and penetrating injuries should be surgically explored and the defects repaired. Penile amputations should be repaired by microsurgical reimplantation if the amputated segment is viable. Strangulation injuries can usually be managed simply by removing the constricting agent, which may require the use of metal cutters. Animal and human bites involving the genitalia should be managed with copious irrigation, appropriate debridement and antibiotic prophylaxis; primary wound closure is contraindicated. Zipper injuries should be managed by removing the top of the zipper slider (see Figure: Zipper removal from penile skin).
To remove a zipper, local anesthetic is injected into the area. Mineral oil is used to lubricate the zipper, and then one attempt is made to unzip the zipper. If this attempt is unsuccessful, a sturdy wire cutter (diagonal cutter) is used to cut the median bar on the top of the zipper slider, which connects its front and back plates. Then the slider falls off in 2 pieces, and the zipper teeth come apart readily.
Diagnose most external scrotal and penile injuries clinically.
Evaluate blunt testicular injuries with ultrasonography.
Do retrograde urethrography to diagnose concomitant urethral injury in patients with either a penile fracture or a penetrating penile injury and hematuria or inability to void.
Surgically repair certain injuries (eg, testicular ruptures, penile fractures, amputations, and penetrating injuries).